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Application e Processed When Properly Completed. Be Sure To Si Application. APPLICATION FOR INSPECTION NO CARBON NECESSARY AND NON -TRANSFERABLE, REVOCABLE, AND SUSPENDABLE SOLID WASTE ENVIRONMENTAL HEALTH PERMIT SOLID WASTE Application is hereby made to carry on business under Permit in the jurisdiction area of San Joaquin Local Health District. 95 204 r Business Name (DBA) Stockton Convalescent Hospital Address 2740 N. California Street Stkn, CA Beverly Enterprises 873 South Fair Oaks Ave. Passadena, CA 91105 z Owner Address Y Firm Partners, Addresses and Telephone Numbers N�A aBusiness Telephone No. (209) 466-3522 Emergency Telephone No. Same Franchise Area Served L Applicants Name (Print) B.A. Mannon - Title Administrator Date5-10-85 Please check Applicable Category(s). Fill in the Required Information, Return all 3 copies. SOLID WASTE DISPOSAL SITE, NO. 39 -AA - NEW SITE PERMIT SOLID WASTE TRANSFER STATION INDUSTRIAL WASTE GENERATOR STATIONARY COMPACTOR (20 yd. or greater) HAZARDOUS WASTE GENERATOR INFECTIOUS WASTE GENERATOR WASTE STORAGE FACILITY NEW SITE APPLICATION FEE MIXED WASTE RECYCLING FACILITY MANURE STORAGE SITE SITE EXEMPTION APPLICATION I hereby certify that I have prepared this application and that to the best of my knowledge it is true and correct. APPLICANT'S SIGNATURE x�%�(Q%TJ�Ln�Y�— Title �%L"til; Date FOR DEPARTMENT USE ONLY Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ HOURLY ❑ Jan. 1 & Received By Jan. 31 ❑ July 1 & Received By July 31 VEHICLES AND CONTAINERS (Fill Supplemental Form) BASE ❑ COMPACTOR TRUCK No. to be permitted ❑ COLLECTION TRUCK No. to be permitted ❑ ROLL -OFF TRACTOR No. to be permitted ❑ ROLL -OFF TRAILER No. to be permitted (No. to be used dually as Limited Waste Hauler Vehicle) ------------ ------------- RENDERING, RENDERING, VEHICLE No. to be permitted ❑ MANUER VEHICLE No. to be permitted ❑ FERTILIZER VEHICLE No. to be permitted ❑ LIMITED WASTE HAULER VEHICLE No. to be permitted ❑ LIMITED WASTE HAULER TRAILER No. to be permitted ❑ 20 + YARD BINS, DUMPSTERS, Roll -off & Other Containers No. to be permitted I hereby certify that I have prepared this application and that to the best of my knowledge it is true and correct. APPLICANT'S SIGNATURE x�%�(Q%TJ�Ln�Y�— Title �%L"til; Date FOR DEPARTMENT USE ONLY Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ HOURLY ❑ Jan. 1 & Received By Jan. 31 ❑ July 1 & Received By July 31 BASE EXPLANATION BILLING DATE REMITTANCE DATE $ REMITTED AMOUNT DUE REMIT CHECKED AMOUNT FEE FEE LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit Nos. Issuance Date Mailed Delivered